Determinants of adherence to tuberculosis therapy among patients receiving Directly Observed Treatment from a district hospital in Pretoria, South Africa

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Background: The incidence of tuberculosis in South Africa last measured at 834 in 2015 as reported by the World Bank. Out of these cases, only 54% cured and 13% of patients stop taking treatment. In Pretoria, Gauteng, comprehensive TB services are available in 87% of clinics and all these clinics offer the Directly Observed Treatment Short-course (DOTS) programme and help to diagnose TB and trace contacts. However, the average Pretoria district DOTS coverage has decreased from 88.8% to 84.7% in the last few years. The health district's cure rate as at 2012 is 61%, and its average rate of successful treatment of all new smear positive cases is 66% since 2005. Certain factors that determine patients' adherence towards TB treatment have been identified to include demographic, psychosocial and health system related factors. However, the WHO identified factors responsible for or predisposing patients to discontinue the DOTS programme have not been investigated in the study setting. Aim: The aim of this study was to assess the determinants of adherence to DOTS therapy amongst TB patients who commenced TB treatment at the TB clinic of a district hospital during April – June 2014. Methodology: A quantitative study was conducted using a descriptive cross-sectional design. An inclusive sample was drawn from adults in the DOTS programme receiving first line treatment during the 6-month period prior to commencement of the research. The calculated sample size was 234 individuals. The data collection tools included a questionnaire, 2-day recall and 30-day recall instruments and pill counts. Data were analysed using EPI info version 7 which included descriptive statistics to measure level of adherence. Associations between identified factors and adherence to TB treatment were also determined. Results: The final sample size was 80 participants of which 76% were male. The mean composite adherence rate was found to be 94% while the proportion of the patients who achieved adherence of 95% and above was 75%. Identified barriers to adherence include forgetfulness, lack of transport fare on clinic appointment days, patients not feeling well and so were not strong enough to attend clinic appointments. On the other hand, the role of treatment supporters and counseling were found to have a positive impact on adherence to DOT in this setting. The use of reminders such as cell phones and alarm-radios were also identified as facilitators to adherence. Patients' knowledge of consequences for not taking medications as prescribed, which is closely linked with counseling, was found to be significantly associated with adherence in this study. Education status of participants was found to be significantly associated with adherence to DOTS (p = 0.01), when considering the pharmacy refill pill count as the adherence measure. Significant association was found between DOTS treatment regimens and 30-day recall adherence measures (p = 0.002). Significant association was also found for medication side effects and the adherence measures of 2-day recall, 30-day recall and pill count with p = 0.04; p = 0.03; p = 0.05 respectively There were significant associations between age and adherence with two of the adherence measures (30-day recall and pill count) at p = 0.002 and p = 0.003 level of significance respectively. Significant association was observed between duration of DOTS treatment when dichotomised using the mean treatment period (17 weeks) as the cut-off point and any of the adherence measures. Conclusion: The factors identified in this study can be classified into patient related factors, economic factors, social factors and health care workers and health system related factors. Furthermore, the factors at these different levels impact on one another and their improvements need to be made at all these levels to address the challenges facing TB patients to achieve optimal treatment adherence. This study is the first study of its kind in the study location and the findings have provided useful baseline data on the adherence rates and some insights into the major factors that affect adherence among patients on DOTS at a Pretoria West District Hospital. However further qualitative and quantitative studies are required to explore the factors influencing adherence further.